27 January 2015 Archwilydd Cyffredinol Cymru Auditor General for Wales NHS Waiting Times for Elective Care in Wales I have prepared and published this report in accordance with the Government of Wales Act 1998 and 2006. The Wales Audit Office study team comprised Mark Jeffs, Gareth Jones, Verity Winn and Steve Ashcroft under the direction of David Thomas. Huw Vaughan Thomas Auditor General for Wales Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ The Auditor General is independent of the National Assembly and government. He examines and certifies the accounts of the Welsh Government and its sponsored and related public bodies, including NHS bodies. He also has the power to report to the National Assembly on the economy, efficiency and effectiveness with which those organisations have used, and may improve the use of, their resources in discharging their functions. 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If you require any of our publications in an alternative format and/or language please contact us using the following details: Telephone 029 2032 0500, or email [email protected] Contents Summary 6 Recommendations 11 1 Many patients face long waits for treatment and some other UK countries are doing better against more stringent targets 13 Although most patients are treated within 26 weeks and many patients are happy to wait, performance is getting worse and is some way from meeting the targets 15 A significant minority of patients feel they wait too long and some patients are deteriorating and coming to harm while on a waiting list 19 Scotland and England are performing better against more stringent referral to treatment time targets 22 Some patients wait longer than the official recorded waiting times show and there is scope to use the existing data to better reflect patient experiences 25 2 The main reason for long waiting times is the inability, despite a lot of effort, to sustainably match supply with patient demand 27 The Welsh Government did not adequately consider how to sustain waiting time performance after 2009 and its approach to performance management has not been successful in securing achievement of waiting time targets 28 Health boards’ planning of waiting times is generally unsophisticated and they have struggled to prioritise waiting times against competing pressures 31 Despite incremental improvements, existing capacity is not being used to meet demand as effectively as it could be 36 4 NHS Waiting Times for Elective Care in Wales 3 The NHS will need hard work and bravery to act on emerging ideas for whole-system reform and pockets of innovation 47 Through prudent healthcare in particular, the NHS is now challenging the current design of the elective care system 48 The Welsh Government is moving towards clearer strategic leadership which will require bravery and determination across the NHS to enable whole-system change 55 Appendices Appendix 1 – Audit methods 61 NHS Waiting Times for Elective Care in Wales 5 Summary 1 During our lifetimes, most of us will need some form of elective – or planned – NHS care. That could involve a diagnosis from a consultant or some form of planned surgery. The amount of time that patients wait to get a diagnosis or to get treatment matters a good deal to them. It is not the only thing that matters, but waiting times has been the key measure against which the Welsh Government and the public judges the performance of the elective care system. Since 2009, the NHS in Wales has been working to a target whereby at least 95 per cent of patients on a waiting list should be waiting less than 26 weeks and nobody should wait more than 36 weeks1. The waiting list includes patients at all stages from their referral through to starting treatment. Figure 1 provides a snapshot overview of the NHS waiting list in Wales in March 2014. 2 This report looks at how long patients are waiting for elective care. The report does not focus on emergency care nor care related to cancer – which is subject to separate targets – although it does consider the impact of prioritising these areas for elective care. In carrying out our work, we have sought to answer the overall question: ‘Is NHS Wales’ overall approach to managing elective waiting times effective?’ To answer this question we looked at current performance, the underlying causes of waiting times performance and NHS Wales’ plans to better manage waiting times. Our conclusions and our key findings are set out in this report. We are also publishing additional supporting information for readers interested in seeing more of the detailed analysis and data underpinning our findings: a a technical report with more data on performance and the causes of long waiting times; b a summary of the responses to patient surveys conducted as part of our review; and c a compendium of good and promising practice. 3 Our overall conclusion is that while the vast majority of patients are treated within 26 weeks, the current approach does not deliver sustainably low waiting times. However, emerging plans do have the potential to improve the position if they are implemented effectively. 1 Some specific services are excluded from the waiting times target, including fertility treatment, screening services and routine dialysis. Further detail can be found in the publication Rules for Managing Referral to Treatment Waiting Times. 6 NHS Waiting Times for Elective Care in Wales Figure 1 – A snapshot of the waiting list at March 2014 Outpatients patients awaiting rst 227,787 outpatient appointment. Outpatient Department Median wait: 6% 8.6 waiting over weeks 26 weeks X-ray Department patients awaiting 66,920 a diagnostic test. No median wait due to data consistency issues. patients awaiting a decision 36,263 following a diagnostic test. Outpatient Department Median wait: 12% 12.9 waiting over weeks 26 weeks Inpatients patients waiting for admission 87,472 as an inpatient or day case. Median wait: 26% 16.3 waiting over weeks 26 weeks NHS Waiting Times for Elective Care in Wales 7 4 It is important to state that the vast majority of patients are seen and treated within 26 weeks and many are happy to wait for their treatment. Across 2013-14, the median waiting time of a patient on a waiting list in Wales was 9.9 weeks2. Figure 1 provides a snapshot of the median waits of patients at various stages of the patient pathway at the end of March 2014. However, performance against the Welsh Government waiting time targets has been declining significantly since 2009. In March 2014, 11 per cent of patients on the waiting list had been waiting more than 26 weeks and three per cent more than 36 weeks. There is evidence from independent reviews and our own survey that a minority of patients are coming to harm as a result of long waiting times. Moreover, despite some differences in the way they are measured, waiting times in Wales are longer than those in England and Scotland. The data which is available does not allow a similar comparison to be made to Northern Ireland. 5 The causes for the relatively long waits are complex but boil down to the inability of NHS Wales as a whole to sustainably match the supply of healthcare with demand for services. Some of the key factors that we see as having led to the current position are: a the Welsh Government not updating its approach since 2009 to reflect the challenges of meeting waiting time targets in an environment of increasing financial and resource constraints, though this is now being addressed through the integrated medium-term planning process; b a lack of recurrent capacity for elective care and a consequent over-reliance on short-term funding for activity outside of normal working hours to deliver quick but unsustainable reductions in waiting times; c over-optimistic health board plans that are based on meeting targets rather than what can realistically be achieved; d greater financial, staffing and bed resource pressures compared to similar parts of the UK; e pressures from rising demand for elective care; f pressures from emergency admissions, urgent cancer care and follow-up appointments which reduces the resources available for routine patients; and g inefficient use of existing resources and capacity, including an over-reliance on seeing and treating patients in hospital when they could be managed in a primary care or community setting. 2 The ‘median waiting time’ is the length of time waited by the person in the ‘middle of the queue’. For example, if there were 100 patients in the queue and they were all lined up in the order of time they had been waiting, the median waiting time would be the length of time the 50th person had waited.